Archived: Boniface House

Boniface House is a residential care home registered to provide care for up to 46 older and younger people, some of whom are living with dementia, physical disabilities or sensory impairments. At the time of the inspection 18 people were living in the home.

Boniface House has six separate units, each of which has separate adapted facilities. During the inspection two of the units were not being used.

People’s experience of using this service and what we found

Systems and processes were not always effective in identifying when information was incorrect, missing or conflicting. The provider had multiple auditing processes in place. However, they had not identified the concerns we found on inspection regarding the recording of information.

People’s care plans and risk assessments were not always sufficient to ensure staff had all the necessary information. We found some people did not have risks assessed or mitigating strategies recorded for known risks and some care plans had not been kept up to date.

Unexplained injuries were not always investigated, and some injuries had not been recorded with all the essential information required to ensure staff and healthcare professionals had all the information required to evaluate these injuries.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

People were supported by well trained and safely recruited staff. People were exceptionally positive about staff and used word such as, kind, caring, compassionate and lovely when describing them.

Staff felt supported within their roles and enjoyed working at Boniface House. Staff told us they worked well as a team and their wellbeing was considered by management.

Information was shared between staff and management. Regular supervisions and meeting were arranged to share information and give suggestions. Feedback was requested from people, relatives, professionals and staff to support improvements.

People had their needs met. Staff were supportive towards people and encouraged independence. Staff promoted people’s right to dignity and respect. People were able to make choices on gender of staff supporting them with personal care.

People had their healthcare needs met. Staff made referrals to appropriate healthcare support as required. Staff supported people to make and access appointments as needed. Significant people were kept up to date on their loved ones process and any incidents or accidents that may occur.

People were supported to access any religious or cultural community required. People had access to religious services and staff were aware of people’s preferences, needs and wants. Staff encouraged people to participate in hobbies and interests.

People’s communication needs were documented, and staff followed people’s preferred communication method. We observed staff talking to people in a respectful caring manner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

This service was registered with us on 1 April 2021 and this is the first rated inspection.

A focused inspection was completed on 14 April 2022, the service was inspected but not rated. We found the provider to be in breach of Regulation 12, due the provider failing to assess, prevent and control the spread of infections. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulation 12. However, at this inspection we found the provider was in breach of regulation 17.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to oversight and governance at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Boniface House is a residential care home registered to provide care for up to 46 older people, some of whom are living with dementia. At the time of the inspection 20 people were living in the home.

Boniface House accommodates up to 46 people across six separate units, each of which has separate adapted facilities. During the inspection two of the units were not being used as they were being refurbished.

People’s experience of using this service and what we found

The provider failed to implement all the government guidance in their policies and practice in relation to staff changing their clothes before and after their shift.. This placed people at risk of the spread of infections including COVID-19.

Staff had access to personal protective equipment (PPE), were using this appropriately and understood the importance of good hand hygiene. Visitors were screened and tested before entering the building to prevent the risk of infection from COVID-19. Staff were vaccinated as per the regulatory requirement.

The registered manager regularly monitored the service and acted on the findings of audits to improve the service. Staff meetings kept staff informed of changes and involved in improving the service.

There were enough staff deployed to provide people’s planned care, however, there were many staff vacancies, so the provider used regular agency and the management team to provide care.

People received their medicines as prescribed . Staff received training in managing medicines and their competencies had been checked.

Staff were recruited using safe recruitment procedures.

People’s risks were assessed and reviewed regularly or as their needs changed.

Staff understood their roles in safeguarding people from abuse or improper treatment. The managers were responsive to staff concerns.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 1 April 2021 and this is the first inspection.

The last rating for the service under the previous provider was Good, published on 25 September 2019.

Why we inspected

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about infection control. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with infection control, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

We have identified a breach in relation to infection prevention and control at this inspection.

Please see the action we have told the provider to take at the end of this report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.